PLATELET RICH PLASMA INJECTIONS are part of a group of emerging powerful techniques to treat a number of painful disorders including arthritis, ligament tears (such as rotator cuff injuries of the soulder) and many others. Our blood contains various kinds of cells in suspension including red blood cells, white blood cells and platelets. The fluid remaining after removal of all these cells is called plasma. Specifically, platelets are fragments of larger precursor cells called megakaryocytes. Among several functions, platelets are normally gathered to the sites of tissue injury to stop bleeding and to enhance repair and regeneration of damaged tissues. Platelets contain high concentrations of growth and regenerative factors which are poured into bodily areas needing repair. Among several things, growth factors signal the body to initiate a healing response. PRP is plasma containing a high concentration of platelets but no red or white blood cells. By injecting PRP into injured areas, it has been theorized that PRP can optimize your body’s ability to heal.

How is platelet rich plasma or PRP obtained?

To develop a PRP preparation, a relatively small amount of the patient’s own blood (about 50 ml in average) must be first drawn from a vein. This is about 10 times less than the volume of blood generally required for a blood donation. Using special equipment and centrifuges, the platelets are separated from other blood cells, purified and their density increased in the plasma.

How is platelet rich plasma or PRP delivered to the sites of injury?

This is done through simple injections. The injection sites are aseptically cleansed, like for any other types of injection and then, using image guidance, the physician will inject the PRP solution into the affected area. Image guidance, such as fluoroscopy or ultrasound, dramatically increases the safety, efficacy and accuracy of the procedure.

Which conditions can be treated with platelet rich plasma injections or PRP?

PRP has been used in operating rooms for several decades to help with wound healing and to stimulate bone formation in spinal fusion surgery. More recently, PRP has been used to treat a variety of injuries ranging from damage cartilage in arthritic joints to ligament tears in professional athletes.

PRP is currently being used to treat pain associated with a spectrum of injuries including: arthritis of many joints including of the knee, hip, lumbar spine, foot, hand and other sites, chronic tendon and ligament sprains and strains. These type of injuries can be associated with neck or back pain and pain in the joints (such as shoulder, knee and hip pain), among others. Shoulder injuries such as rotator cuff tendonitis and tears, arthritis of the knee, hip, foot, etc, have been treated with PRP.

Two of the Pittsburgh Steelers’ biggest stars, Hines Ward and Troy Polamalu, used PRP treatment before winning the Super Bowl. At least one major league pitcher, about 20 professional soccer players and hundreds of club level athletes have also used the procedure to accelerate repair of injuries. For the soccer fans, Cristiano Ronaldo of the Real Madrid has also been treated and returned quickly to the field after a traumatic injury by treating the damaged area with platelet rich plasma injections.

How effective is PRP?

It is important to recognize that, although widely used, PRP is an emerging new therapy. As such, there is no extensive evidence of efficacy in placebo controlled double blind clinical trials. However, in a few double blind placebo controlled clinical trials available (such as those in which neither the doctor nor the patient knows who gets PRP and who gets the placebo) PRP was shown to be better than placebo for treating pain associated with knee arthritis. There are many other studies suggesting efficacy, but these are preliminary (meaning that they were not double blinded). For example, in a prospective evaluation of 40 patients with hip arthritis and pain, statistically significant reductions in pain and improvement of function were reported after PRP treatment in 60% of the patients at 7 weeks and 6 months following the PRP injections (Rheumatology, 2011; Volume 51, pages 144-150). Treatment was not effective in 11 patients although 10 of these patients presented with prior radiographic evidence of advanced arthritic damage.

In a study presented at the American Academy of Orthopedic Surgeons meeting in 2013 (Chicago, IL), researchers reported on the effects of PRP on patients afflicted with shoulder pain due to a partial rotator cuff tear. The study comprised 204 patients with poor shoulder function and restricted range of motion. The PRP group consisted of 102 patients treated with PRP injections and the comparison control group consisted of 102 patients treated with local anesthetics and steroids. According to the researchers, function and range of motion were clearly greater in the PRP group than in the steroid group (67.7 percent versus 24.9 percent, respectively). In addition, at 1-year follow-up, only 3 patients in the PRP group had undergone surgery for severe pain, whereas 48 patients in the steroid group had required surgical intervention. “At 12-month follow-up, patients who received a series of PRP injections were 16 times less likely to have undergone surgical intervention than patients who received corticosteroid injections,” the authors concluded. For further details of this study, click here

It is also fair however, to mention that there is controversy in the clinical literature. Some studies including patients with tennis elbow and in Achilles tendinopathy (injury to the heel tendon) did not show benefits with PRP injections when compared with saline injections or injections of whole blood, although ALL GROUPS in the studies showed improvement. Therefore, several theories have been proposed to explain the observed improvements. One is that PRP may only work in some but not in all types of injuries. Another important explanation of some of the controversies is that the technique is not standardized and in may cases, suboptimal preparations of platelets have been made. FOr platelet rich plasma injections to work, the concentration of platelets needs to be within a certain range. Several studies have shown clearly that too few or too many platelets in the preparation are ineffective. Also, the type of equipment employed is critical because red blood cell or white blood cell contamination can also alter the results. In our clinics, we have extensively researched all these factors for optimal treatment of our patients. The other factor affecting the results is how the platelets are delivered. Imaging guidance is critical for safety and accuracy of the injections. Also, we found stimulation of healing by multiple needle prickling into an injured area (tenotomy technique) stimulates healing and by doing this, we can see improved healing in some cases. Because many studies claiming a positive beneficial effect have no blinded controls or have a limited sample size or used different uncontroled techniques for the platelet rich plasma preparation, it is Dr. Pappolla’s view at this time that PRP should be tried when other standard therapies have failed and pain continues and interferes with the patient’s quality of life. It is important that the patient also conducts his own research on the therapy and considers all pros and cons before making a decision.

Despite the controversies and the negative results, the appeal of PRP has soared to new heights when athletes of the caliber and prestige of Tiger Woods, Rafael Nadal or Cristiano Ronaldo and players like Troy Polamalu and Hines Ward reported that PRP cured them. Currently, thousands of doctors and about 500 hospitals are offering the treatment. It is also widely used in veterinarian medicine.

How long do I have to wait to see results?

The improvement, if present, will continue for months after the injection. Most patients are satisfied with one treatment but it is common to have treatment boosters for larger defects or more complex pathologies.

How safe are PRP injections?

The risks of PRP are those of any other injections such as bleeding and infection. Because no foreign substances or drugs are used, there are no risks of adverse reactions to the injected platelets.

Is PRP treatment covered by insurance? Because PRP is a new therapy, insurance companies generally classify it as “experimental” and do not cover the cost of this treatment. It will likely take years for the insurance companies to cover the cost of this therapy.